COMPANY OVERVIEW

Business Name:

FEIN: $

DBA:

Location Address:

Policy Expiration Date:

Est. Sales :

Contractor’s License #:

Website:

Mailing Address (if different from above):

ESTIMATED PAYROLLS

CLASS CODE EST. PAYROLL # FULL TIME EMPLOYEES

# PART TIME EMPLOYEES

$

$

$

$

$

$

CORPORATION/OFFICERS

TITLE NAME % OF OWNERSHIP

EXCLUDED FROM COVERAGE

% Yes No

% Yes No

% Yes No

% Yes No

% Yes No

Total 100%

PAYROLL/PREMIUM HISTORY (3 YEARS)

YEAR PREMIUM TOTAL PAYROLL $ $

$ $

$ $

Landscape Supplemental Application

LANDSCAPE WORKERS’ COMPENSATION SUPPLEMENTAL APPLICATION

Describe your general operations, who you service, and how the work is performed. Include state(s) in which you operate.

States: Years in business:

CLAIMS INFORMATION Who is point of contact for your work related injuries? Email: Phone:

Do you have a Preferred Medical Provider for your work related injuries? Yes No Provider name(s):

AUTO Are vehicles company owned? Yes No Number of vehicles?

Are vehicles taken home? Yes No Number of drivers?

Employee’s use personal vehicles for work? Yes No Are road tests given? Yes No

Yes No Involved in DMV “PULL” program? Yes No Group Transportation (vans, bus, etc.)? verage number of

? Radius of operations?

Group transportation of 5 or more employees? If yes, what % of total operations considers group transportation?

STANDARD INFORMATION Written application? Yes No Reference checks? Yes No

Pre/Post hire physical? Yes No Pre-hire drug test? Yes No

Any interchange in labor? Yes No Post-accident drug test? Yes No

Subcontractors used? Yes No If yes, what purpose? If yes, what are annual subcontractor receipts?

Yes No Do you lease employees or usetemporary labor?

Do you employ independent contractors 1099 (not subcontractors)? Health benefits offered ? Yes No If yes, who is the health provider?

% of employees enrolled? % % of health benefits paid byemployer? %

Total employees insured?

Yes No Paid vacation? Yes No Paid sick leave?

Average tenure of employees?

Has ownership changed in last 5 years? Yes No

LANDSCAPE WORKERS’ COMPENSATION SUPPLEMENTAL APPLICATION

SAFETY PROGRAM Do you have an active safety incentive program? Yes No If yes, what type of incentives?

Do you have a safety director? Yes No # of employees OSHA 10 certified?

Accident investigation program? Yes No Safety meeting frequency?

CPR training? Yes No If yes, # of employees enrolled?

Return to work program (light duty)? Yes No Enforce pre-work stretch? Yes No

Any other safety designations or certifications?

LANDSCAPE OPERATIONS

Maintenance: Installation/Construction:

Single Family Homes % Municipal % Single Family Homes % Municipal % HOA, Condo, Townhome, Apartment % Median % HOA, Condo, Townhome,

Apartment % Median % Commercial, Industrial, Retail Centers % Highway % Commercial, Industrial,

Retail Centers % Highway %

Government % Government % Total 100% Total 100%

Chemical Lawn Care Application/Fertilization: Irrigation Installation/Maintenance:

Single Family Homes % Municipal % Single Family Homes % Municipal % HOA, Condo, Townhome, Apartment % Median % HOA, Condo, Townhome,

Apartment % Median % Commercial, Industrial, Retail Centers % Highway % Commercial, Industrial,

Retail Centers % Highway %

Government % Government % Total 100% Total 100%

If you do installation what % is hardscape? % What % of installation is softscape? %

Involved in any Wrap or “OCIP” projects? Yes No Reforestation or habitat restoration? Yes No

TREE TRIMMING OPERATIONS

Yes No % If yes, % of operations of above ground tree trimming? % of operations above 15ft.? %

Do you do any above ground tree trimming?

# of certified arborists?

% of operations climbing? % % of operations aerial lift? %

OTHER THAN TREE TRIMMING

Yes No % Installation/removal of trees greater than 15 gallons? % of operations removing mature trees? %

If yes, % of operations planting trees greater than 15 gallons?

Stump grinding? Yes No

% of operations climbing? % % of operations aerial lift? %

Association affiliation: State Assoc. ISA member PTCA NALP Other

%

% %

LANDSCAPE WORKERS’ COMPENSATION SUPPLEMENTAL APPLICATION

CERTIFICATES OF INSURANCE Do you need a Blanket Waiver of Subrogation? Yes No

PAYROLL Do you anticipate payroll will continue to grow, decline, or stabilize?

Please elaborate on any questions above if necessary

Please provide detail to any claim above $20,000